Study ID |  | Clemson 2016 [28] | López Cabezas 2006 [29] | Rich 1995 [30] | ||||
---|---|---|---|---|---|---|---|---|
TCM Component | Definition | Pre hospital discharge | Post hospital discharge | Pre hospital discharge | Post hospital discharge | Pre hospital discharge | Post hospital discharge | |
1 | Screeninga | Targets the key evidence-based risk factors from those who would benefit from the TCM intervention. According to Hirschman [31] the risk factors for eligible patients are: ≥ 5 active chronic conditions, a recent fall, deficits in basic activities of daily living (ADL), a diagnosis of dementia or poor performance on cognitive impairment screening tools, history of mental or emotional health problems and hospitalization within the past 30 days or ≥ 2 hospitalizations within the past six months. | X | a | X | a | X | a |
2 | Staffinga | Consists of the delivery and coordination of care is executed by the same master’s prepared advanced practice registered nurse (APRN), who assumes primary responsibility for the care of patients. | Xb | a | Xb | a | Xb | a |
3 | Maintaining Relationships | Key feature of TCM to maintain and promote respectful and trusting relationships with patients and their family caregivers. This includes not only home visits and telephone calls, but also availability of the APRN or the health professional in charge of the intervention seven days a week. | X | X | X | X | X | X |
4 | Engaging Patients and Caregivers | Consists of the development and application of a discharge education and care plan in collaboration with the medical team, the patient and the caregivers. This plan includes the patient goals and preferences, among others. | X | Â | Â | Â | X | Â |
5 | Assessing/Managing Risks and Symptoms | Comprehensive and targeted assessment to determine changes in the patient health status as well as a complete management of symptoms to prevent their onset or their risks. | X | X | X | X | X | X |
6 | Education/Promoting Self-Management | Involves the implementation of educational and behavioral strategies to meet the patients and caregivers learning needs related to an adequate and immediate response to the worsening of symptoms. | Â | Â | X | X | X | X |
7 | Collaborating | Refers to the furthering of consensus on the patients’ plan of care between patients and members of the healthcare team. |  |  |  |  | X | X |
8 | Promoting Continuity | Highlights the follow up of the patients by the same medical care team, in order to avoid interruption of the patients’ plan of care. | X | X | X | X | X | X |
9 | Fostering Coordination | Encourages the active communication between healthcare team and community-based practitioners, where the APRN in collaboration with patients, caregivers and team care members may identify the need for additional services. | Â | Â | Â | Â | X | X |
Total: | 6/9 | 3/7 | 6/9 | 4/7 | 9/9 | 6/7 |